1. Weight and Procedural Abortion Complications: A Systematic Review
Patients with higher body weight have been found to be at higher risk for unintended pregnancy and may detect pregnancy at later gestations, hindering access to early abortion care. However, many outpatient health centers offering abortion care do not offer services to patients above a certain BMI given concern for a higher risk for complications, instead referring them for hospital-based services and delaying care. In this systematic review, the authors investigated whether higher body weight was an independent risk factor for procedural abortion complications. In six studies involving almost 39,000 patients, the authors found that none of the studies showed a statistically significant association between higher body weight and procedural abortion complications overall. A subgroup analysis did show that patients with a BMI of ≥ 40 undergoing second-trimester abortion were at higher risk of complications. There was also a small but statistically significant difference in the length of procedure time for patients with higher body weights, though without associated increased rates of complications. The authors call for the greater inclusion of patients with higher BMIs in research but conclude that routinely referring patients with higher body weights for hospital-based abortion procedures is not evidence-based and delays access to time-sensitive care, pushing patients into receiving care at later gestations.
2. Self-Managed Abortion
Self-managed abortion (SMA) refers to actions people may take to end their pregnancies outside the formal healthcare system. In this ACOG committee statement, the authors discuss the various reasons and methods patients may try to self-manage an undesired pregnancy, including physical trauma and medications, herbs, and substances. They discuss the role of the providers in supporting patients who may present for care after SMA and recommend managing any rare complications as they would after any spontaneous pregnancy loss. The authors stress a harm-reduction approach in caring for SMA patients and urge providers to be wary of the potential for criminalization, counseling providers to be aware of regional laws regarding SMA and avoid unnecessary interviewing or documentation on SMA patients. The guideline also directly opposes mandatory reporting of pregnancy outcomes or prosecution of pregnant patients for alleged fetal harm. Given the frequency of SMA, providers caring for reproductive-aged patients can use this guideline to care for patients considering or presenting after SMA in a manner that is nonjudgemental and avoids the potential for additional legal harm.
3. A Lexicon for First-Trimester US: Society of Radiologists in Ultrasound Consensus Conference Recommendations
Many pregnant patients undergo pelvic ultrasound during their first trimester, and the terms used in describing ultrasound findings can have significant implications for clinicians’ understanding, patients’ emotional distress, and legal consequences in abortion restrictive states. In this set of recommendations from the Society of Radiologists in Ultrasound, a multisociety panel was convened to identify first trimester ultrasound terms that were 1) clear, specific, scientifically based, and medically appropriate, 2) acceptable to both clinicians and patients, and 3) minimized bias and harm. The authors provide thorough lists of commonly used synonymous ultrasound terms and provide specific preferred terminology, including “cardiac activity” (rather than “heartbeat” or “viable pregnancy”), “early pregnancy loss” (rather than “pregnancy failure”), and “ectopic pregnancy” for both extrauterine and intrauterine pregnancies with abnormal implantation sites. This lexicon serves as a helpful guideline for standardizing first-trimester ultrasound terms to minimize clinical confusion and avoid imputing bias or emotionally laden terms onto medical findings.
4. Patient acceptability of intra-amniotic digoxin versus intracardiac lidocaine for inducing foetal demise prior to second trimester medical abortion: a prospective cohort
Patients seeking abortion care at periviable gestations and after fetal viability may undergo induction of fetal asystole before abortion for reasons ranging from patient preference to institutional or legal policies to avoid the possibility of periviable extramural delivery. There are several evidence-informed methods described for safely inducing fetal asystole before abortion, including intracardiac/intrafunic lidocaine or potassium chloride, and intrafetal or intraamniotic digoxin. However, less is known about patients’ preferences regarding these modalities. In this prospective cohort study, 151 patients between 20 and 28 weeks of pregnancy who received either intracardiac lidocaine or intraamniotic digoxin for fetal asystole were surveyed about their experiences. The authors reported that while the mean time to asystole was significantly shorter in the lidocaine group, more patients in the digoxin group reported their injection experience as “as expected” or “not bad” in comparison to the lidocaine group and were more likely to recommend this option to a friend. The authors conclude that intraamniotic digoxin for fetal asystole had superior patient acceptability when compared to intracardiac lidocaine and suggest that providers can discuss this as part of their counseling when reviewing options with patients.
5. Changes in Availability of Later Abortion Care Before and After Dobbs v. Jackson Women's Health Organization
While the majority of abortions occur in the first trimester, abortion care in the second and third trimesters is an important component of reproductive healthcare. The Dobbs decision in 2022 significantly impacted later abortion care, both by permitting states to drastically limit or ban abortion but also by making it more likely that patients would have to travel for abortion care, leading them to seek care at later gestations. In this research using the ANSIRH abortion facility database, the authors investigated trends in national abortion service availability both before and after the Dobbs decision from 2021 to 2023. They determined that while 64 new facilities started advertising procedural abortion services during this time, approximately 115 facilities closed or stopped offering procedural services. There was a 5% decrease in the total number of facilities offering abortion care after 14 weeks (from 327 to 309) and a 16.7% decrease in facilities offering care at or later than 24 weeks (from 60 to 50). The greatest decrease in facilities was seen in the South US. The authors conclude that these trends reflect the ongoing decline in abortion care availability for patients later in pregnancy and stress the importance of efficient referral networks, supporting abortion training, opening new facilities in strategic geographic locations, and generally continuing to advocate against abortion restrictions.
6. Expectations and experiences of pain during medical abortion at home: a secondary, mixed-methods analysis of a patient survey in England and Wales
Although medication abortion (MAB) is common and safe, patients frequently report pain that is more intense or different from what they expected. In 2021, researchers in England and Wales designed a study to analyze pain experiences for individuals undergoing MAB up to 10 weeks gestational age and found that patient satisfaction increased with increasing options for pain medication. For this secondary analysis, the authors reviewed qualitative data from the 2021 study with the aim of improving current counseling and resources for patients. Participants were asked to reflect on their pain experience using both numerical and free-text descriptors. Almost 1600 individuals were included in this analysis, and 48.4% reported more pain than expected, with many commenting that comparing MAB pain to menstrual cramps was not adequate preparation for their experience. Other recommendations from the results included reminders to stock up on supplies (such as heating pads or pain medication) and to consider having a companion during the MAB for company and support. These suggestions have led to revisions of patient resources and are useful to read for providers who frequently describe MAB pain to patients.
7. Society of Family Planning Clinical Recommendation: Medication management for early pregnancy loss
This document reviews clinical recommendations from the Society of Family Planning on medication management for early pregnancy loss (EPL), specifically when there is still a gestational sac visualized within the uterus. For the purposes of their discussion, the authors defined EPL as a failed intrauterine pregnancy up to 13 weeks and 6 days gestational age. Although the majority of the discussion focuses on medication management, one of the authors’ primary recommendations is that stable patients with EPL should be offered all options: expectant, medication, and procedural management. They proceed to provide comprehensive, evidence-based information on EPL diagnosis, duration of expectant management, and administration of Rh immune globulin. While mifepristone and misoprostol are the most effective regimens for medication management of EPL, the authors also provide information on best practices if using misoprostol alone. Follow-up, access, and pain management are also addressed. This comprehensive document is an essential resource for any providers who offer medication management of EPL.
8. Healthcare provider communication and current contraceptive use among transgender men and gender-diverse people: results from an online, cross-sectional survey in the United States
Transgender men and gender-diverse (TMGD) people experience numerous barriers to receiving accurate, comprehensive information about contraception, including discrimination, lack of provider education, and inadequate research on their contraceptive needs. However, adequate contraceptive counseling has been shown to help individuals achieve their reproductive goals and is an important component of healthcare for TMGD people. The authors of this study performed an analysis of survey data on TMGD individuals in the United States and their experiences with contraception, including communication with healthcare providers on this topic. Almost 1700 TMGD people participated in this survey study, which included questions about contraception use, if contraception had been discussed with a healthcare provider (and if so, who initiated it, and when), and the participants’ comfort with the conversation. Overall, the study revealed ongoing gaps for TMGD individuals: a third of participants had never discussed contraception with a provider. However, a discussion about contraception was positively associated with current contraception use, most strongly with long-acting reversible contraception, but many TMGD individuals reported that they did not feel comfortable asking all their questions during these appointments. These results highlight a need for additional research on the best way to deliver contraceptive care to TMGD people in order to reduce barriers to access and improve reproductive autonomy.
9. Changes in Support for Advance Provision and Over-the-Counter Access to Medication Abortion
Since Dobbs v Jackson in June 2022, abortion restrictions have forced increasing numbers of patients to seek abortion care through remote or virtual care delivery. Because mifepristone’s in-person administration requirement was removed by the FDA in April 2021, medication abortion (MAB) can be accessed without an in-person visit. Two additional care delivery models have the potential to further increase access to medication abortion. In the first, advance provision (AP), patients would receive mifepristone and misoprostol from a clinician before becoming pregnant, thereby storing the medication for future use. Over-the-counter (OTC) medication abortion would permit individuals to buy mifepristone and misoprostol directly at their pharmacies, without a prescription. Limited research supports the use of both AP and OTC delivery systems, but neither is currently available to most people. The authors of this study surveyed individuals assigned female at birth to assess their perspectives on AP and OTC delivery of medication abortion before and after the Dobbs decision. More than 13,600 individuals completed the survey between 2021 and 2023. The results noted a significant increase in both support for and personal interest in both AP and OTC access to medication abortion, particularly in areas with restricted abortion access. These findings suggest that ongoing research is needed to determine how medication abortion can be better delivered to patients, possibly through AP and OTC methods.
10. Accuracy of Survey-Based Assessment of Eligibility for Medication Abortion Compared to Clinician Assessment
Medication abortion is well-established as extremely safe and is the most commonly sought form of abortion in the United States. However, due to increasing restrictions on abortion access, numerous studies are being conducted on novel forms of care delivery for medication abortion. Pre-existing studies have shown that most patients can accurately estimate their gestational age without using an ultrasound, therefore decreasing the need for in-person visits. The authors of this paper sought to explore this theme even further by studying whether patients are able to establish their own eligibility for medication abortion using a survey format. More than 1300 individuals participated in the survey, in which they were asked about their gestational age and medical conditions that would prevent them from safely undergoing medication abortion, such as anemia, or currently using an IUD. These responses were then compared to a clinical evaluation. The authors found that fewer than 2.5% of the participants screened themselves as “eligible” when they were, in fact, ineligible for medication abortion. Instead, the vast majority of survey responses agreed with clinical assessments. These results suggest that it may be safe and feasible to allow patients to self-assess for medication abortion eligibility, thereby increasing abortion access and patient autonomy.
